Insights of Rashtriya Bal Swasthya Karyakram: a strength, weaknesses, opportunities, and threats analysis

INTRODUCTION

In India, with 25 million births a year, 40 percent account for neonatal deaths during labour or during the first 24 hours after childbirth followed by pre-maturity (35%), neonatal infections (33%), birth asphyxia (20%), and congenital malformations (9%) are among the major causes of new-born deaths.¹ Nearly 3.5 million babies are born too early, in which out of every 100 live births, 6 to 7 have birth defects which translate to 1.7 million birth defects annually, leading to 9.9% of all new-born deaths, and one million get discharged each year from special new-born care units (SNCUs) with a high risk of death, stunting, and developmental delay.² Over 70% of various nutritional deficiencies are affecting preschool children while early childhood developmental delays are commonly found in at least 10% of children. These delays if not intervened timely may lead to permanent disabilities including cognitive, hearing/vision impairment.³ Although there are several vertical programs aimed at controlling blindness, deafness, and iodine deficiency, all of which have specific objectives, it is important to converge these programs, as children can suffer from multiple overlapping problems that need to be screened and managed holistically, a program titled “child health screening and early intervention services” was launched in 2013 by ministry of health and family welfare, government of India, as “RBSK” under national health mission, pragmatically and innovatively to improve quality of life for all children, from 0-18 years of age, with a special focus on children at risk by a systemic approach of prevention, early identification and management of selected 30 health conditions distributed under 4Ds: defects at birth, deficiencies, diseases and developmental delays including disabilities from birth to 18 years of age in a holistic manner.^4-6 The intervention includes medical, surgical, or even therapy-based interventions such as physiotherapy, occupational therapy, speech and language therapy, vision therapy, behavioural therapy, psychological assessment, and therapy. Such services are provided as per the child’s requirement which could be either at primary, secondary/ tertiary health centres at zero cost to families that constitutes principles of equity and approach to universal health.⁷

Though the process of establishment has been a little delayed than expected, most of the states are now progressing and are in various stages. Since the endeavour involves extensive resources and efforts in terms of dedicated and trained human resources, infrastructure, equipment, and inter-sectorial linkages, challenges are hugely decelerating overall pace of operationalization of program, present study attempted to assess the SWOT analysis of RBSK scheme which would aid in identifying potential areas for government engagement/ action to combat childhood morbidities and propose efficient coping strategy to overcome the threats.

SWOT ANALYSIS

A SWOT analysis is a systematic tool that refers to the strengths and weaknesses which are the internal characteristics of the system and compared with other systems which that needs to be addressed respectively while Opportunities and Threats are external factors in the environment to make greater inputs or cause troubles to the system which should be avoided. In this review study, a SWOT analysis was carried out to give an insight into the RBSK. A literature review was conducted to gather information from various articles relating to the program.

Various databases were searched, including original studies, reviews, commentaries, and government guidelines from two electronic databases: PubMed and search engines (Google Scholar and Google). The relevant keywords used in the search were “RBSK”, and “SWOT analysis”. Information and guidelines posted on the Ministry of Health website were also used. Articles included were in the English language, published during the period from (2016-2022). Articles in languages other than English, with no full text, were excluded. Each summary was classified according to the following SWOT parameters: 1) strength, 2) weakness, 3) opportunities and 4) threats.

DISCUSSION

Health programs and plans are often evaluated using SWOT analysis.⁸ This effective tool enabled the study to individuate the main strengths, weaknesses, opportunities, and, threats of RBSK. Statements on each main category of the study were obtained through the content analyses of published articles and summarized into SWOT categories, where the Strengths and weaknesses cover internal aspects of the program, whereas opportunities and threats cover the external environment factors.

Strengths

RBSK program provides an effective platform for early identification and intervention for children from birth to 18 years of age to cover 4 ‘D’s including disability. The program thus signifies that it corresponds to the maternal, reproductive, child health, new-born, and adolescent health strategy, and India new-born action plan.^9,10 Through the systemic approach, first-level screening is done at all delivery points. After 48 hours to 6 weeks, the screening of new-borns is done by ASHA at home as a part of the home-based new-born care package. Outreach screening is also done by dedicated mobile health teams for 6 weeks to 6 years at Anganwadi centres and 6-18 years’ children at schools. (3) A formative research study carried out in eight districts across 5 states found that 25% of children were screened to have congenital heart disease.¹¹ After screening the management of the screened children is done at primary, secondary, and tertiary intervention services at medical colleges.⁴ Through good referral support by District Early Intervention Center.¹² Once the child is screened and referred it would be ensured that the necessary treatment/intervention is delivered at zero cost to the family. This is supported by a year-wise RBSK progress report of Chhattisgarh state where around 27 lakh children were screened, treated, or referred among 28 districts.¹³ Thus, the major strength of the RBSK scheme is the continuum of care extending over different phases of the life of a child over the first 18 years.^14,15

Weakness

There is an unavailability of certain diagnostic facilities and deficient human resources in mobile health teams and at DEICs. In a DEIC in Odisha state, screening for sickle cell disease and thalassemia could not be done due to the non-availability of a blood testing facility for Hb electrophoresis. In terms of staffing, at DEIC Audiologist, Speech therapist, Optometrist, and Lab technician posts were vacant, and a lack of infrastructure was identified.¹² In rural areas, many children were undiagnosed and deprived of treatment even for curable diseases. In states like Maharashtra, though there is a reliance on diagnostic camps such as 2D echo camps for confirming congenital heart diseases leading to sometimes, 2-3 months of waiting period for diagnosis and confirmation. This hidden part of these children with defects, and disabilities constitute a major part of childhood mortality.¹⁴ The outbreak of COVID-19 disrupted routine aid services utilization all over the world, which arise a necessity to create a sturdy framework and implementation of essential services. Therefore, the lack of preparedness for child screening during an outbreak significantly shows an impact on the program for reducing the services.¹⁶

Opportunities

Opportunities arise for capacity building and orientation in referring all new-born babies discharged from SNCU for screening and follow-up. Each baby discharged from SNCU can be tracked through available health care facilities such as AWW, ASHA, health workers, Mother and child tracking system (MCTS), and by mobile phones through SMS.¹² In addition, the referral system yields epidemiological data on all 4D’s for future reference. The healthcare service provision under the program can be improved as it can increase the efficiency of healthcare system for area-specific services.¹⁷ Support of social media can serves an opportunity for better dissemination and increase public awareness of RBSK scheme.

Threats

The major threat of this program is unawareness of the disease condition among parents. The reasons for inadequate uptake of services included concerns about, the long distance to the treatment centre, inconvenient timings, and loss of daily wages. This is similar to a study in Bangalore, where the additional reasons for the non-utilization of services were the migrant population, treatment at private hospitals due to inconvenient timings, and waiting for surgery.¹⁸ The discontinuation of the treatment is also seen mainly due to the long waiting time in therapy sessions and transportation costs.¹⁹

Table 1 represents the SWOT analysis of RBSK with its main objective to improve quality of life of children from birth to 18 years by eliminating out-of-pocket expenses as a major strength, followed by a lack of human resources. Although parental ignorance of utilizing the services appears to pose a major threat, all possible opportunities can be utilized to overcome these challenges.

Limitations

The SWOT analysis identifies the issues but does not prioritize the identified concerns. This type of review analysis may have been influenced by the author's view on the program, as the literature review carried out may have been overlooked or oversimplified. Despite the limitations, this SWOT analysis will be a useful tool for corresponding decision-makers.

CONCLUSION

India, a country where implementation of a program at a level of a billion population becomes a mission for achieving the sustainable development goals (SDGs), RBSK is a step towards ‘Health for All’, providing measurable improvements in child’s quality of life. The major achievements were observed in surgeries done for congenital heart diseases, congenital cataracts, club foot, cleft palate/lip, and neural tube defects in addition to the distribution of hearing aids and spectacles free of cost. The shortage of resources is of major concern, where the recruitment of drop out and vacant staff posts can be filled at the earliest and parents should be motivated to utilize these services. This paper paves the way for decision-making to work on weaknesses, avoid threats, and utilize the highlighted opportunities using SWOT analysis. We also expect that policymakers/stakeholders can use this preliminary analysis for improving the health status of children to achieve their full potential by strengthening the program.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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